Management and prevention of pertussis infection in neonates

Clinical characteristics and molecular detection of Bordetella pertussis in hospitalized children with a clinical diagnosis of whooping cough in Peru

Background and Objectives

Pertussis is an infectious disease caused by the Gram-negative bacterium Bordetella pertussis. In Peru, actual public health programs indicate that vaccination against B. pertussis must be mandatory and generalized, besides all detected cases must be reported. The objective of this study was to determine the prevalence of B. pertussis among children under five years of age with a presumptive diagnosis of whopping cough in Cajamarca, a region located in northern Peru.

Materials and Methods

The population of this cross-sectional study were children under 5 years old hospitalized as presumptive cases of pertussis during December 2017 to December 2018. The nasopharyngeal samples were analyzed by real-time PCR for the detection of B. pertussis.

Results

B. pertussis was identified as PCR + in 42.3% of our sample (33/78). The clinical presentation that was observed most frequently includes paroxysmal coughing (97%), difficulty breathing (69.7%), cyanosis (72.7%) and post-tussive emesis (60.6%). Additionally, pneumonia was the most observed complication (33.3%). Four of the patients with PCR+ for B. pertussis presented only lymphocytosis, five only leukocytosis, two patients with decreased leukocytosis and lymphocytes and only one patient with leukopenia and relative lymphocytosis. There was a percentage of 84.8% of unvaccinated children in the PCR+ group. Finally, the mother was the most frequent symptom carrier (18.2%).

Conclusion

In conclusion, in the studied population there is a high rate of PCR+ cases for B. pertussis. Laboratory values may show leukopenia or lymphopenia in patients with pertussis. It is necessary to use appropriate laboratory diagnostic tests in all infants with respiratory symptoms for B. pertussis. Since, the clinical diagnosis overestimates the diagnosis of pertussis.

FIGO Statement: Vaccination in pregnancy

Pregnant women and their fetuses are among the vulnerable populations that can be severely affected by communicable diseases. As such, some vaccines such as the influenza and the Tdap (tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis) vaccines are strongly recommended in each pregnancy, with generally safe profiles. Other vaccines can be offered based on risk factors, and only when the benefits of receiving them outweigh the risks. Development of vaccines against group B streptococcus infection and respiratory syncytial virus infection are of great importance. In this paper, the recommendations for administration of each vaccine during pregnancy are discussed. The FIGO Committee for Safe Motherhood and Newborn Health Committee endorses the recommendations to vaccinate all pregnant women against influenza during the influenza season at any time during the pregnancy and against Tdap preferably between the 27th and 36th weeks of pregnancy in each pregnancy.

Lurking Infantile Pertussis: Experience from a Tertiary Care Center in Northern India

Objectives The aim is to study the clinical laboratory profile and outcome of infants with laboratory confirmed pertussis.

Methods In this retrospective study, records of 30 infants with laboratory confirmed pertussis, admitted to the pediatric department of a tertiary care hospital, were reviewed. Clinical features, laboratory parameters, and outcomes were noted.

Results Median (interquartile range age was 10 (7–24.5) weeks, with a male preponderance. Large majority (60%) of enrolled infants were less than 16 weeks of age and nine (30%) developed pertussis even before 8 weeks of age. Cough was universal (100%), followed by rapid breathing (73%), fever (70%), and apnea (10%). Bubble continuous positive airway pressure (CPAP), nasal prongs oxygen, and invasive ventilation were required in 15 (54%), 11 (39%), and 2 (7%) infants, respectively; 12 (40%) needed to be admitted to the pediatric intensive care unit. Anemia was observed in 28 (93%) and leukemoid reaction in 15 (50%). All except one were discharged successfully. None of the mothers had received tetanus, diphtheria, and pertussis or Tdap vaccination during pregnancy.

Conclusion Our study reports the continued occurrence of infantile pertussis in the community, suggesting reconsideration of our vaccination policy, including maternal immunization.

Neonatal pertussis: an emerging issue of concern

Neonatal pertussis is a resurging disease, possibly due to waning immunity in pregnant women. We report seven cases of neonatal pertussis (Bordetella pertussis DNA PCR positive) in this retrospective study conducted at a tertiary care teaching hospital in north India over eight months (March to October 2018). All except one were male infants and presented at the age of 14-30 days with paroxysmal cough in all, four had fever, four had respiratory distress, three had similar illness in the family, and two had leucocytosis. All recovered well with azithromycin. The duration of hospital stay was 5-7 days. A strong suspicion of neonatal pertussis in neonates with paroxysmal cough and similar family history should be maintained as the prognosis is excellent, if treated appropriately.

Clinical Findings and Management of Pertussis

Pertussis is an endemic highly infectious vaccine-preventable disease. The disease is a major cause of childhood morbidity and mortality. In the most recent years, the re-emergence of pertussis occurred, and many efforts were done to identify the possible causes. Certainly, more effective laboratory methods have a role in making the diagnosis easier. However, sub-optimal efficacy of available vaccines as well as their limited duration of protection could explain the resurgence of the disease. Many forms and clinical features of the disease, ranging from the most classical to atypical and very nuanced forms, have been reported. There are many aspects that influence the clinical features of the pathology, such as a previous immunization or infection, patient's age, gender and antibiotic treatment. A prompt suspect and a rapid diagnosis of pertussis is fundamental for an appropriate clinical management and for preventing pertussis complications, especially in children. However, under a clinical point of view, pertussis is often difficult to be diagnosed. A prompt treatment may decrease the duration and severity of cough; the cornerstone drugs are the macrolides. Although prompt diagnosis and effective therapy are important for pertussis control, only with a broad vaccination coverage will be possible to reduce circulation of Bordetella pertussis.

Bordetella pertussis in children hospitalized with a respiratory infection: clinical characteristics and pathogen detection in household contacts

OBJECTIVE

Describe the prevalence of Bordetella pertussis via PCR in children under 5 years old hospitalized as probable cases of pertussis and report the most common clinical features among them.

RESULTS

A positive PCR result for B. pertussis was observed in 20.5% of our samples (18/88), one-third of them were from infants between 2 and 3 months old. The most common symptoms were paroxysms of coughing (88.9%), difficulty breathing (72.2%), cyanosis (77.8%) and fever (50%). The mother was the most common symptomatic carrier (27.8%), followed by uncles/aunts (22.2%) among children with pertussis.

Systematic review found that there was moderate evidence that vaccinating healthcare workers prevented pertussis in infants

This systematic review investigated the effectiveness of vaccinating healthcare workers against pertussis on the occurrence of nosocomial pertussis outbreaks or infections among unprotected infants. We focused on eight studies, with five different study designs, that involved 39,129 healthy adolescents and adults, 115 healthcare workers, 2000 simulated healthcare workers and a simulated population of 200,000 people.

CONCLUSION

There was moderate evidence that tetanus-diphtheria acellular pertussis vaccinations for healthcare workers were effective in preventing pertussis in all age groups and specifically in infants. The results must be interpreted with caution due to the low quality and heterogeneity of the studies.

Dismantling the Taboo against Vaccines in Pregnancy

Vaccinating pregnant women in order to protect them, the fetus, and the child has become universal in no way at all. Prejudice in health professionals add to fears of women and their families. Both these feelings are not supported by even the smallest scientific data. Harmlessness for the mother and the child has been observed for seasonal, pandemic, or quadrivalent influenza, mono, combined polysaccharide or conjugated meningococcal or pneumococcal, tetanus toxoid, acellular pertussis, human papillomavirus, cholera, hepatitis A, Japanese encephalitis, rabies, anthrax, smallpox, yellow fever, mumps, measles and rubella combined, typhoid fever, inactivated or attenuated polio vaccines, and Bacillus Calmétte Guerin vaccines. Instead, the beneficial effects of influenza vaccine for the mother and the child as well as of pertussis vaccine for the child have been demonstrated. Obstetrician-gynecologists, general practitioners, and midwives must incorporate vaccination into their standard clinical care. Strong communication strategies effective at reducing parental vaccine hesitancy and approval of regulatory agencies for use of vaccines during pregnancy are needed. It must be clear that the lack of pre-licensure studies in pregnant women and, consequently, the lack of a statement about the use of the vaccine in pregnant women does not preclude its use in pregnancy.

Protecting Newborns Against Pertussis: Treatment and Prevention Strategies

Pertussis is a potentially severe respiratory disease, which affects all age groups from young infants to older adults and is responsible for an estimated 195,000 deaths occurred globally in 2008. Active research is ongoing to better understand the pathogenesis, immunology, and diagnosis of pertussis. For diagnosis, molecular assays (e.g., polymerase chain reaction) for detection of Bordetella pertussis have become more widely available and support improved outbreak detection. In children, pertussis vaccines have been incorporated into routine immunization schedules and deployed for pertussis outbreak control. Lower levels of vaccine coverage are now being observed in communities where vaccine hesitancy is rising. Additionally, recognition that newborn babies are at risk of pertussis in the USA and UK has led to recommendations to immunize pregnant women. Among adolescents and older adults in the USA, Tetanus Toxoid, Reduced Diphtheria Toxoid and Acellular pertussis (Tdap) Vaccines are recommended, but substantial individual- and system-level barriers exist that will make achieving national Healthy People 2020 targets for immunization challenging. Current antimicrobial regimens for pertussis are focused on reducing the severity of disease, reducing rates of sequelae, and minimizing transmission of infection to susceptible individuals. Continued surveillance for pertussis will be important to identify opportunities for reducing young infants' exposure and reducing the impact of outbreaks among school-aged children. Laboratory-based surveillance for newly emerging strains of B. pertussis will be important to identify strains that may evade protection elicited by currently available vaccines. Efforts to develop new-generation pertussis vaccines should be considered now in anticipation of vaccine development programs, which may require ten or more years to deliver a licensed vaccine.